Screening for Depression Among Pregnant and Postpartum Women

Associations Between Early-Pregnancy Vitamin D Status and Postpartum Depressive and Anxiety Symptoms

OBJECTIVE

Maternal postpartum depressive and anxiety symptoms are risk factors for subsequent maternal and child mental health problems. Little is known about the potential role of antepartum vitamin D and C-reactive protein (CRP) in the etiology of maternal postpartum affective symptoms. We investigated associations between antepartum vitamin D status and postpartum depressive and anxiety symptoms and whether antepartum CRP mediated these associations.

METHODS

In 2483 participants of the Amsterdam Born Children and their Development prospective cohort, maternal serum vitamin D and CRP were measured at a median of 13 weeks' gestation. Vitamin D status was defined as deficient (≤29.9 nM), insufficient (30-49.9 nM), sufficient (50-79.9 nM), or normal (≥80 nM). Maternal depressive symptoms (Center for Epidemiologic Studies-Depression) and anxiety (State-Trait Anxiety Inventory) were assessed 3 months postpartum.

RESULTS

After adjustments for confounders, vitamin D deficiency was only associated with increased postpartum anxiety symptoms ( B = 0.17, 95% confidence interval [CI] = 0.03-0.30, p = .017) compared to normal vitamin D levels (≥80 nM). In women not taking vitamin D supplementation ( n = 2303), vitamin D deficiency was associated with increased postpartum depressive and anxiety symptoms ( B = 0.14, 95% CI = 0.03-0.28, p = .045; and B = 0.17, 95% CI = 0.03-0.32, p = .015). Antepartum CRP did not mediate these links.

CONCLUSIONS

We found some evidence that antepartum vitamin D deficiency was associated with increased postpartum affective symptoms, especially in women not taking vitamin D supplementation. Clinical trials should determine whether vitamin D supplementation can reduce the risk for postpartum affective disorders.

Preconception maternal posttraumatic stress and child negative affectivity: Prospectively evaluating the intergenerational impact of trauma

The developmental origins of psychopathology begin before birth and perhaps even prior to conception. Understanding the intergenerational transmission of psychopathological risk is critical to identify sensitive windows for prevention and early intervention. Prior research demonstrates that maternal trauma history, typically assessed retrospectively, has adverse consequences for child socioemotional development. However, very few prospective studies of preconception trauma exist, and the role of preconception symptoms of posttraumatic stress disorder (PTSD) remains unknown. The current study prospectively evaluates whether maternal preconception PTSD symptoms predict early childhood negative affectivity, a key dimension of temperament and predictor of later psychopathology. One hundred and eighteen women were recruited following a birth and prior to conception of the study child and were followed until the study child was 3-5 years old. Higher maternal PTSD symptoms prior to conception predicted greater child negative affectivity, adjusting for concurrent maternal depressive symptoms and sociodemographic covariates. In exploratory analyses, we found that neither maternal prenatal nor postpartum depressive symptoms or perceived stress mediated this association. These findings add to a limited prospective literature, highlighting the importance of assessing the mental health of women prior to conception and providing interventions that can disrupt the intergenerational sequelae of trauma.

Patterns and predictors of perinatal posttraumatic stress symptoms: A latent transition analysis

BACKGROUND

Pregnancy is a time of increased risk for intimate partner violence (IPV), yet there is a dearth of prospective research examining the relationship between IPV and posttraumatic stress symptoms (PTSS) in the perinatal period. Further, relationships among different types of IPV and perinatal PTSS remain understudied.

METHODS

Latent class and transition analyses were used to examine classes of PTSS in pregnancy and postpartum, the longitudinal patterns of transitions across these classes, and the role of IPV types, childhood adversity, and depressive symptoms in PTSS presentation. Participants (N = 238) were drawn from two longitudinal studies of high-risk perinatal women.

RESULTS

Four latent PTSS classes emerged: High, Avoidant, Hypervigilant, and Low. Childhood adversity (χ²(3) = 13.09, p = .004), prenatal depression (χ²(3) = 17.58, p = .001), and psychological IPV (χ²(3) = 10.51, p = .01) were associated with membership in High, Avoidant, and Hypervigilant classes. Women with low prenatal PTSS continued to have low levels at postpartum. Women in higher severity classes during pregnancy tended to transition into classes with adjacent, and often lower, levels of symptom severity postpartum. Women in the High PTSS class in pregnancy with elevated levels of depression were significantly more likely to remain in the High PTSS class or transition into the Avoidant class at postpartum, compared to the Low PTSS class, χ²(3) = 11.84, p = .008.

LIMITATIONS

Relatively modest sample size precluded examination of a broader range of symptoms consistent with PTSD.

CONCLUSIONS

Findings highlight the importance of individualized approaches to assessing, monitoring, and treating perinatal PTSS.

Prevalence and associated factors of perinatal depression among working pregnant women: a hospital-based cross-sectional study

Perinatal depression is a major public health problem having serious negative impacts on personal, family, and child developmental outcomes. This study aimed to determine the prevalence of major depressive disorder (MDD) and its associated factors in working pregnant women. This descriptive, cross-sectional study was performed on 389 working pregnant women enrolled from four Tunisian public maternity hospitals. Data collection tools were the sociodemographic, obstetric, family relationships, and work environment questionnaire, and the Center for Epidemiologic Studies Depression Scale (CES-D). The mean score of depression was 27.39 ± 6.97 and 76.1% of women had major depressive symptoms using cutoff points on the CES-D ≥ 23. Family income, diagnosis with a chronic illness, history of depression, and employment categories were associated with major depressive symptoms. In multivariate analyses, family income and work posture were significantly associated with MDD. These results suggest an increased burden of MDD during pregnancy in Tunisian women. Prevention, early detection, and interventions are needed to reduce the prevalence of perinatal depression.

Exercise, Mediterranean Diet Adherence or Both during Pregnancy to Prevent Postpartum Depression-GESTAFIT Trial Secondary Analyses

Targeting lifestyle behaviors during pregnancy is crucial to prevent the highly prevalent postpartum depression and its consequences. In these secondary analyses of an intervention trial to investigate the effects of concurrent exercise training on postpartum depression, we aimed to investigate the potential role of Mediterranean diet (MD) adherence on the exercise effects. A total of 85 pregnant women met the per-protocol criteria (exercise n = 46, control n = 39). The exercise program was delivered in 60 min sessions, 3 days/week, from the 17th gestational week until birth. Women's dietary habits were assessed with a food frequency questionnaire. The Mediterranean Food Pattern (an MD index) was derived from it to assess MD adherence. We used the Edinburgh Postnatal Depression Scale to assess postpartum depression. The postpartum depression score was not statistically different between control and exercise groups (p > 0.05). A higher consumption of fruits (β = -0.242, p = 0.022), lower intake of red meat and subproducts (β = 0.244, p = 0.020), and a greater MD adherence (β = -0.236, p = 0.027) were associated with lower levels of postpartum depression. Greater adherence to the MD during pregnancy was associated with fewer depressive symptoms and a lower risk of postpartum depression. Postnatal depression was not reduced by prenatal exercise. Promoting fruit consumption while controlling the intake of red meat during pregnancy might prevent postnatal depression.

Construct Validity and Responsiveness of Instruments Measuring Depression and Anxiety in Pregnancy: A Comparison of EPDS, HADS-A and CES-D

Depression and anxiety occur frequently in pregnancy and may have unfavourable consequences for mother and child. Therefore, adequate symptom measurement seems important. Commonly used instruments are the Center for Epidemiologic Studies Depression Scale (CES-D), the Edinburgh Postpartum Depression Scale (EPDS), and the Hospital Anxiety and Depression Scale, anxiety subscale (HADS-A). We compared the (1) structural and (2) longitudinal validity of these instruments. The data originated from a study on the effectiveness of an Internet intervention for pregnant women with affective symptoms. (1) A confirmatory factor analysis was used to estimate the construct validity. The theoretical factorial structure that was defined in earlier studies of the CES-D and the EPDS, but not the HADS-A, could be sufficiently replicated with acceptable CFI and RMSEA values. (2) Since there were two measurements in time, the hypotheses concerning plausible directions of the change scores of subscales that were (un)related to each other could be formulated and tested. In this way, longitudinal validity in the form of responsiveness was estimated. Ten of sixteen hypotheses were confirmed, corroborating the longitudinal validity of all constructs, except anhedonia, probably due to inconsistent conceptualization. The HADS-A seems less suitable to screen for anxiety in pregnancy. Anhedonia needs better conceptualisation to assess the change of symptoms over time with the CES-D and the EPDS.

The Effects of Breastfeeding on Maternal Mental Health: A Systematic Review

Background: Breastfeeding has many positive effects on the health of infants and mothers, however, the effect of breastfeeding on maternal mental health is largely unknown. The goal of this systematic review was to (1) synthesize the existing literature on the effects of breastfeeding on maternal mental health, and (2) inform breastfeeding recommendations. Materials and Methods: A literature search was conducted in electronic databases using search terms related to breastfeeding (e.g., breastfeeding, infant feeding practices) and mental health conditions (e.g., mental illness, anxiety, depression), resulting in 1,110 records. After reviewing article titles and abstracts, 339 articles were advanced to full-text review. Fifty-five articles were included in the final analysis. Results: Thirty-six studies reported significant relationships between breastfeeding and maternal mental health outcomes, namely symptoms of postpartum depression and anxiety: 29 found that breastfeeding is associated with fewer mental health symptoms, one found it was associated with more, and six reported a mixed association between breastfeeding and mental health. Five studies found that breastfeeding challenges were associated with a higher risk of negative mental health symptoms. Conclusions: Overall, breastfeeding was associated with improved maternal mental health outcomes. However, with challenges or a discordance between breastfeeding expectations and actual experience, breastfeeding was associated with negative mental health outcomes. Breastfeeding recommendations should be individualized to take this into account. Further research, specifically examining the breastfeeding experiences of women who experienced mental health conditions, is warranted to help clinicians better personalize breastfeeding and mental health counseling.

A systematic review of screening for perinatal depression and anxiety in community-based settings

Screening for perinatal depression and anxiety in community-based maternal and child health settings may help close the detection and treatment gap among women at higher risk for these conditions. We aim to review perinatal depression and anxiety screening tools, timing, and follow-up processes for positive screens in community-based settings. We conducted a systematic review of the literature to identify papers describing screening and interventions for perinatal depression and anxiety in community-based settings. We identified 49 papers describing 47 studies of perinatal depression or anxiety screening in community-based settings. The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently used screening tool. Referral and referral tracking for those who screened positive for symptoms were inadequately described. Types of training and technical assistance provided for screening varied widely. It is feasible and acceptable to screen for perinatal depression in community settings, but there is a need for systematic research examining which screening tools to use, the ideal frequency of screening, and referral completion rates. There is a lack of information regarding perinatal anxiety screening and a lack of uniformity in training regarding screening in community-based settings. Future studies should compare the efficacy of screening in community-based settings to screening in healthcare settings.

The mediational role of social support in the relationship between stress and antenatal anxiety and depressive symptoms among Australian women: a mediational analysis

Background

Pregnancy can be a stressful period for most women and their family members, and the mental wellbeing of pregnant women can face serious challenges. Social support can play a role in improving the psychological well-being of pregnant women by enhancing the stress coping ability and alleviating stressful conditions. The current study aimed to assess the mediating effects of social support in the relationship between perceived stress and depressive symptoms as well as anxiety symptoms during pregnancy among Australian women.

Methods

Of the 8,010 women who completed Survey 6 of the 1973–78 Australian Longitudinal Study on Women’s Health (ALSWH) cohort in 2012, those who reported being pregnant (n = 493) were included in the current analyses. Antenatal depressive and anxiety symptoms were assessed using the 10 item Center for Epidemiological Studies Depression (CES-D-10) scale, and the 9-item Goldberg Anxiety and Depression scale (GADS) respectively. The 19 item-Medical Outcomes Study Social Support index (MOSS) was used to examine social support. A parallel mediation model was used to explore the mediational role of each domain of social support between perceived stress and antenatal depressive and anxiety symptoms.

Result

The study found that emotional/informational support has a partial mediating effect on the relationship between perceived stress and antenatal depressive symptoms (β = 0.371, 95% CI: 0.067, 0.799) and on the relationship between perceived stress and antenatal anxiety symptoms (β = 0.217, 95% CI: 0.029, 0.462). Affectionate support/positive social interaction and tangible support was found to play no significant mediation role between stress and antenatal depressive and anxiety symptoms.

Conclusions

Emotional/informational support appears to play a mediating role in the relationship between stress and antenatal depressive as well as between stress and antenatal anxiety symptoms. In order to further protect pregnant women from the effects of stress, policy makers and maternal health professionals are advised to develop community-based social support programs to enhance prenatal psychosocial support and ensure pregnant women have adequate emotional/information support.

Social support is a resource or a means that an individual can use to cope with stressful events and improve psychological wellbeing. It improves emotional and physical well-being and promotes health for a successful pregnancy. However, the relationship between domains of social support and antenatal depressive and anxiety symptoms remains understudied in Australia. Therefore, our study intended to examine the mediating role of domains of social support in the linkage between stress and depressive and anxiety symptoms during pregnancy among Australian Women.

Data were obtained from Survey 6 of the 1973–78 ALSWH cohort, which was conducted in 2012, and those who reported being pregnant were part of the study (n = 493, aged 34–39 years). Social support provided for a pregnant woman was the outcome variable, assessed using the 19-item Medical Outcomes Study Social Support index (MOS-SSS-19 item). A parallel mediation model was used to explore the mediational role of each domain of social support between perceived stress and antenatal depressive and anxiety symptoms.

Emotional/informational support plays a mediating role in the relationship between stress and antenatal depressive as well as between stress and antenatal anxiety symptoms. So, to further protect pregnant women from the effect of stress, policymakers and maternal health professionals are advised to develop community-based social support programs.

A Technology-Based Pregnancy Health and Wellness Intervention (Two Happy Hearts): Case Study

BACKGROUND

The physical and emotional well-being of women is critical for healthy pregnancy and birth outcomes. The Two Happy Hearts intervention is a personalized mind-body program coached by community health workers that includes monitoring and reflecting on personal health, as well as practicing stress management strategies such as mindful breathing and movement.

OBJECTIVE

The aims of this study are to (1) test the daily use of a wearable device to objectively measure physical and emotional well-being along with subjective assessments during pregnancy, and (2) explore the user's engagement with the Two Happy Hearts intervention prototype, as well as understand their experiences with various intervention components.

METHODS

A case study with a mixed design was used. We recruited a 29-year-old woman at 33 weeks of gestation with a singleton pregnancy. She had no medical complications or physical restrictions, and she was enrolled in the Medi-Cal public health insurance plan. The participant engaged in the Two Happy Hearts intervention prototype from her third trimester until delivery. The Oura smart ring was used to continuously monitor objective physical and emotional states, such as resting heart rate, resting heart rate variability, sleep, and physical activity. In addition, the participant self-reported her physical and emotional health using the Two Happy Hearts mobile app-based 24-hour recall surveys (sleep quality and level of physical activity) and ecological momentary assessment (positive and negative emotions), as well as the Perceived Stress Scale, Center for Epidemiologic Studies Depression Scale, and State-Trait Anxiety Inventory. Engagement with the Two Happy Hearts intervention was recorded via both the smart ring and phone app, and user experiences were collected via Research Electronic Data Capture satisfaction surveys. Objective data from the Oura ring and subjective data on physical and emotional health were described. Regression plots and Pearson correlations between the objective and subjective data were presented, and content analysis was performed for the qualitative data.

RESULTS

Decreased resting heart rate was significantly correlated with increased heart rate variability (r=-0.92, P<.001). We found significant associations between self-reported responses and Oura ring measures: (1) positive emotions and heart rate variability (r=0.54, P<.001), (2) sleep quality and sleep score (r=0.52, P<.001), and (3) physical activity and step count (r=0.77, P<.001). In addition, deep sleep appeared to increase as light and rapid eye movement sleep decreased. The psychological measures of stress, depression, and anxiety appeared to decrease from baseline to post intervention. Furthermore, the participant had a high completion rate of the components of the Two Happy Hearts intervention prototype and shared several positive experiences, such as an increased self-efficacy and a normal delivery.

CONCLUSIONS

The Two Happy Hearts intervention prototype shows promise for potential use by underserved pregnant women.

The association between social support and antenatal depressive and anxiety symptoms among Australian women

Background

Antenatal depression and antenatal anxiety adversely affect several obstetric and foetal outcomes, and increase the rate of postnatal mental illness. Thus, to tackle these challenges the need for social support during pregnancy is vital. However, an extensive literature search failed to show a published study on the relationship between domains of social support and antenatal depressive, as well as antenatal anxiety symptoms in Australia. This study examined the association between domains of social support and antenatal depressive and anxiety symptoms among Australian women.

Methods

The current study used data obtained from the 1973–78 cohort of the Australian Longitudinal Study on Women’s Health (ALSWH), focusing upon women who reported being pregnant (n = 493). Depression and anxiety were assessed using the 10 item Center for Epidemiological Studies Depression (CES-D-10) scale, and the 9-item Goldberg Anxiety and Depression scale (GADS) respectively. The 19 item-Medical Outcomes Study Social Support index (MOSS) was used to assess social support. A logistic regression model was used to examine the associations between domains of social support and antenatal depressive and anxiety symptoms after adjusting for potential confounders.

Result

The current study found 24.7 and 20.9% of pregnant women screened positive for depressive and anxiety symptoms respectively. After adjusting for potential confounders, our study found that the odds of antenatal depressive symptoms was about four and threefold higher among pregnant women who reported low emotional/informational support (AOR = 4.75; 95% CI: 1.45, 15.66; p = 0.010) and low social support (overall support) (AOR = 3.26; 95%CI: 1.05, 10.10, p = 0.040) respectively compared with their counterpart. In addition, the odds of antenatal anxiety symptoms was seven times higher among pregnant women who reported low affectionate support/positive social interaction (AOR = 7.43; 95%CI: 1.75, 31.55; p = 0.006).

Conclusion

A considerable proportion of pregnant Australian women had depressive symptoms and/or anxiety symptoms, which poses serious health concerns. Low emotional/informational support and low affectionate support/positive social interaction have a significant association with antenatal depressive and anxiety symptoms respectively. As such, targeted screening of expectant women for social support is essential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04188-4.

Prevalence and determinants of low social support during pregnancy among Australian women: a community-based cross-sectional study

Background

Pregnancy is a time for women in which the need for social support is crucial. Social support reduces stressors and improves the emotional and physical well-being of pregnant women. Women receiving low social support during pregnancy are at risk of substances use, developing mental illness, and adverse birth outcomes. The current study aims to determine the prevalence and determinants of low social support during pregnancy among Australian women.

Methods

Data were obtained from the 1973–1978 cohort of Australian Longitudinal Study on Women’s Health (ALSWH) and those who report being pregnant (n = 493) were included in the current analyses. Social support was assessed using Medical Outcomes Study Social Support index (MOSS). A logistic regression model was applied to identify determinants of low social support, separately for each MOSS domain.

Result

The study found that 7.1% (n = 35) of pregnant women reported low social support. Significant determinants of low emotional support were non-partnered (AOR = 4.4, 95% CI: 1.27, 14.99), difficulty managing on available income (AOR = 3.1, 95% CI: 1.18, 8.32), experiencing depressive symptoms (AOR = 8.5, 95% CI: 3.29, 22.27) and anxiety symptoms (AOR = 2.9, 95% CI: 1.26, 7.03). Significant determinants of low affectionate support were suffering from depressive symptoms (AOR = 5.3, 95% CI: 1.59, 17.99), having anxiety symptoms (AOR: 6.9, 95% CI: 2.21, 22.11) and being moderately/very stressed (AOR: 3, 95% CI: 1.17, 7.89). Significant determinants of low tangible support were difficulty managing available income (AOR = 3, 95% CI: 1.29, 6.95), and being depressed (AOR = 2.8, 95% CI: 1.48, 5.34).

Conclusion

The study revealed that 7.1% of pregnant women reported low social support. Having a mental health problems, being stressed, being from low socio-economic status and being non-partnered were significant determinants of low social support during pregnancy. Maternal health professionals and policymakers can use this information to screen pregnant women at risk of receiving low social support and improve the level of support being provided.

Providing strong social support improves emotional and physical well-being, strengthens social relationships, promotes health, and enhances the stress coping ability of pregnant women. However, pregnant women receiving low social support are at risk of substances use, developing mental illness, and adverse birth outcomes. The current study aims to determine the prevalence and determinants of low social support during pregnancy among Australian women. Data were obtained from Survey 6 of the 1973–1978 cohort of the Australian Longitudinal Study on Women’s Health (ALSWH) (n = 493, pregnant women aged 34–39 years). This cohort is one of ALSWH ongoing community-based study focusing on the health of women in Australia. Social support provided for a pregnant woman was the outcome variable, assessed using the 19-item Medical Outcomes Study Social Support index (MOSS). The prevalence of low social support in each domain was calculated for each of the independent variables. A logistic regression model, using a backward stepwise elimination approach, was employed to identify determinants of low social support. In the final model, the strength of association measured by adjusted odds ratios (AOR) with 95% confidence intervals. The significance level was set at p < 0.05. From the total participant pregnant women, 7.1% of them reported low social support. Significant determinants of low social support among pregnant Australian women were, having a mental illness, being stressed and/or being from low socio-economic status and being non-partnered. Maternal health professionals can use this information to screen pregnant women at risk of receiving low social support as well as develop policy to help enhance the social support being given and the psychological wellbeing being of pregnant women.

Psychosocial and peripartum determinants of postpartum depression: Findings from a prospective population-based cohort. The ABCD study

BACKGROUND

Postpartum depression is prevalent and concerns a serious health problem for women and their families. The current large-scale birth cohort study investigated: (1) the associations of various potential determinants of postpartum depression using a multidimensional approach, and (2) the individual contribution of obstetric and perinatal determinants and pregnancy-specific anxiety to the risk of postpartum depression.

METHODS

This study was based on a large-scale birth cohort study in Amsterdam, the Netherlands (ABCD-study). In 5109 women depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (cut-off ≥16 indicating high risk of postpartum depression). Determinants were assessed using self-report or perinatal registries.

RESULTS

In the final multivariable model, other-Western and non-Western ethnic background, increased antepartum depressive symptoms, increased antepartum anxiety, increased pregnancy-specific anxiety, being unemployed, poor sleep quality, unwanted pregnancy, abuse, multiparity, and congenital abnormality were all independently related to an increased risk of postpartum depression. The strongest risk factors for postpartum depression were antepartum depressive symptoms (adjusted odds ratio (AOR) = 3.86, 95% confidence interval (CI) 3.02-4.92), having a baby with a congenital abnormality (AOR = 2.33, 95% CI 1.46-3.73), and abuse (AOR = 1.95, 95% CI 1.02-3.73). The final model accounted for 24.5% of the variance.

LIMITATIONS

Our dataset did not provide information on social support or maternal and family history of depression. Next to these determinants, future research should include biological factors.

CONCLUSIONS

The determinants identified provide opportunities for the development of multidimensional early screening and early intervention strategies for women with an increased risk of postpartum depression.

Perception of infant sleep problems: the role of negative affectivity and maternal depression

STUDY OBJECTIVES

To investigate whether the interaction between infant negative affectivity and maternal depressive symptoms is associated with the degree to which mothers perceive infant sleep to be problematic at 6 months postpartum, independent of infant sleep and sociodemographic factors.

METHODS

Infant negative affectivity and maternal depressive symptoms were assessed in a sample of 59 mother-infant dyads at 6 months postpartum using standardized measures. Mothers reported the degree to which they perceived their infant's sleep to be problematic via an item composite of the Sleep Practices Questionnaire. Nocturnal infant sleep variables (duration, number of awakenings) were retrieved from a 2-week infant sleep diary (maternal report).

RESULTS

There was a significant interaction between infant negative affectivity and maternal depressive symptoms in predicting mothers' perceived extent of infant sleep problems. Simple slope analysis showed that high levels of depression were related to higher maternal perception of infant sleep problem scores only among mothers of infants with high levels of negative affectivity. Moreover, infant negative affectivity and maternal depressive symptoms positively predicted perception scores after adjustment for infant sleep, maternal age, and parity (P < .05).

CONCLUSIONS

The current study provides evidence that high levels of maternal depression combined with high levels of infant negative affectivity may contribute to mothers' perceptions of infant sleep problems, independent of infant sleep duration and awakenings. These findings highlight the importance for pediatricians and other health professionals to consider infant temperament in conjunction with mothers' depressive symptoms when addressing mothers' concerns about infant sleep problems.

Effect of Thyroxine Therapy on Depressive Symptoms Among Women With Subclinical Hypothyroidism

OBJECTIVE

To estimate the effect of antenatal treatment of subclinical hypothyroidism on maternal depressive symptoms.

METHODS

We conducted an ancillary study to a multicenter trial in women with singleton pregnancies diagnosed with subclinical hypothyroidism randomized to antenatal thyroxine therapy or placebo. Treatment was discontinued at the end of pregnancy. Women with overt thyroid disease, diabetes, autoimmune disease, and those diagnosed with depression were excluded. Participants were assessed for depressive symptoms using the Center for Epidemiological Studies-Depression scale (CES-D) before starting the study drug (between 11 and 20 weeks of gestation), between 32 and 38 weeks of gestation, and at 1 year postpartum. The primary outcome was maternal depressive symptoms score as assessed using the CES-D. Secondary outcome was the percentage of women who scored 16 or higher on the CES-D, as such a score is considered screen-positive for depression.

RESULTS

Two hundred forty-five (36.2% of parent trial) women with subclinical hypothyroidism were allocated to thyroxine (n=124) or placebo (n=121). Median CES-D scores and the proportion of participants with positive scores were similar at baseline between the two groups. Treatment with thyroxine was not associated with differences in CES-D scores (10 [5-15] vs 10 [5-17]; P=.46) or in odds of screening positive in the third trimester compared with placebo, even after adjusting for baseline scores (24.3% vs 30.1%, adjusted odds ratio 0.63, 95% CI 0.31-1.28, P=.20). At 1 year postpartum, CES-D scores were not different (6 [3-11] vs 6 [3-12]; P=.79), nor was the frequency of screen-positive CES-D scores in the treated compared with the placebo group (9.7% vs 15.8%; P=.19). Treatment with thyroxine during pregnancy was also not associated with differences in odds of screening positive at the postpartum visit compared with placebo even after adjusting for baseline scores. Sensitivity analysis including women who were diagnosed with depression by the postpartum visit did not change the results.

CONCLUSIONS

This study did not achieve its planned sample size, thus our conclusions may be limited, but in this cohort of pregnant women with subclinical hypothyroidism, antenatal thyroxine replacement did not improve maternal depressive symptoms.

Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa

Background

Postpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers.

Objectives

We set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa.

Methods

We conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3–6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs).

Results

Overall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9–1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3–0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0–0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2–0.8).

Conclusions and recommendations

Targeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services.

Prenatal sleep quality and mental health symptoms across the perinatal period: A longitudinal study of high-risk women

BACKGROUND

Trauma-exposed women may be at magnified risk for posttraumatic stress (PTSS) and depression symptoms in the perinatal period, but few studies have examined symptomatology across the perinatal period in high-risk samples. Further, the role of sleep in perinatal symptomatology has been largely neglected in the violence literature, despite its well-established associations to mental health in other samples. This study aimed to examine the trajectory of PTSS and depression symptoms across the perinatal period and the effects of childhood adversity, intimate partner violence and prenatal sleep impairment on PTSS and depression symptoms across the perinatal period.

METHOD

In a longitudinal, prospective study, 101 low-income pregnant women were interviewed during pregnancy, at 6-weeks postpartum, and 4 months postpartum. N = 83 women completed at least 2 interviews and were included in the analyses. Prenatal sleep, childhood adversity, and IPV exposure were assessed at the prenatal interview; PTSS and depression were assessed at all interviews.

RESULTS

Past year IPV was associated with elevated prenatal mental health symptoms and prenatal sleep difficulties were associated with a worsening trajectory in perinatal PTSS.

CONCLUSIONS

Screening for IPV and prenatal sleep difficulties may be paramount in identifying those at risk for the development or exacerbation of mental health symptoms in the perinatal period.

Correlates of Perinatal Post-Traumatic Stress among Culturally Diverse Women with Depressive Symptomatology

Post-traumatic stress disorder (PTSD) is an important and often neglected comorbidity of pregnancy; left untreated, it can lead to serious health complications for the mother and developing fetus. Structured interviews were conducted to identify risk factors of PTSD among culturally diverse women with depressive symptomatology receiving perinatal services at community obstetric/gynecologic clinics. Women abused as adults, with two or more instances of trauma, greater trauma severity, insomnia, and low social support were more likely to present perinatal PTSD symptoms. Perinatal PTSD is prevalent and has the potential for chronicity. It is imperative healthcare providers recognize salient risk factors and integrate culturally sensitive screening, appropriate referral, and treatment services for perinatal PTSD.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

A Socioecological Predication Model of Posttraumatic Stress Disorder in Low-Income, High-Risk Prenatal Native Hawaiian/Pacific Islander Women

INTRODUCTION

Only recently has perinatal posttraumatic stress disorder (PTSD) been researched in any depth; however, the causes and consequences of this serious illness remain unclear. Most commonly, childbirth trauma and interpersonal violence have been reported as contributing factors. However, not all Native Hawaiian/Pacific Islander (NHPI) women who experience these events experience PTSD. The factors affecting PTSD are many and complex, intertwining individual, family, and community contexts. Using a socioecological framework, 3 levels of contextual variables were incorporated in this study (individual, family, and social/community). The purpose of this study was to determine the socioecological predictors associated with prenatal PTSD among NHPI.

METHODS

A case-control design was used to collect retrospective data about socioecological variables from medical record data. The sample was low-income, high-risk NHPI women receiving perinatal health care at a rural community health center in Hawaii who screened positive (n = 55) or negative (n = 91) for PTSD.

RESULTS

Hierarchical logistic regression was conducted to determine socioecological predictors of positive PTSD screening. Although the majority of women (66.4%) experienced some form of interpersonal violence, a constellation of significant predictor variables from all 3 levels of the model were identified: depression (individual level), lack of family support and family stress (family level), and violence (social/community level).

DISCUSSION

Each of the predictor variables has been identified by other researchers as significantly affecting perinatal PTSD. However, it is because these variables occur together that a more complex picture emerges, suggesting the importance of considering multiple variables in context when identifying and caring for these women. Although additional research is needed, it is possible that the significant predictor variables could be useful in identifying women who are at higher risk for PTSD in other similar populations.

A Socioecological Framework to Assessing Depression Among Pregnant Teens

To examine individual, interpersonal, family, and community correlates associated with moderate-to-severe depressive symptoms among pregnant adolescents. A total of 249 primarily African American and Hispanic pregnant adolescents ages 15-18 years were recruited into either an intervention group utilizing Centering Pregnancy prenatal care and case management, or to a comparison group receiving case management only. Moderate-to-severe depressive symptoms were defined as a score ≥16 on the Center for Epidemiologic Studies Depression Scale (CES-D). Intervention and comparison groups did not significantly differ on demographic characteristics or depression scores at baseline. A total of 115 (46.1 %) participants met criteria for moderate-to-severe depressive symptoms at entry into the program. Pregnant adolescents who were moderately-to-severely depressed were more likely to be African American, to have reported limited contact with the father of the baby, and to have experienced prior verbal, physical or sexual abuse. Depressed adolescents also experienced high levels of family criticism, low levels of general support, and exposure to community violence. A significant number of pregnant adolescents were affected by depression and other challenges that could affect their health. Comprehensive interventions addressing these challenges and incorporating partners and families are needed.

Course of depressive symptoms across pregnancy in African American women

INTRODUCTION

Although African American women are at increased risk for antenatal depression, less is known regarding the course of antenatal depression symptoms among African American women. Because pregnancy is a state of rapid physical and mental changes, we examined if depression symptoms changed between the second and third trimesters in a sample of pregnant African American women.

METHODS

A nonprobability sample of women was recruited from obstetrics clinics within a large Midwestern health system. African American women in their second trimester (N = 189) completed an initial study visit; a convenience sample of 37 women (19.6%) completed a second identical study visit during their third trimester. The 20-item Center for Epidemiological Studies Depression Scale (CES-D) was used to measure depressive symptoms; a CES-D score of 16 or higher equates with clinical depression and a CES-D score of 23 or higher indicates major depression. Paired t tests and correlation coefficients were used to estimate change in depression symptoms.

RESULTS

Mean (SD) second- and third-trimester CES-D scores were not statistically significantly different (15.3 [10.6] and 15.1 [10.3], respectively; P = .87) and were moderately and significantly correlated (r = 0.65; P .001). Prevalence of CES-D scores of 16 or higher was 43.2% (n = 16) in the second trimester and 37.8% (n=14) in the third trimester, which was not significantly different (P =.77). Between the 2 visits, 67.6% (n=25) were classified identically with a CES-D scores of 16 or higher with only fair agreement between the 2 measures (kappa = 0.33). Prevalence of CES-D scores of 23 or higher was 27.0% (n = 10) and 21.6% (n = 8) in the second and third trimesters, respectively, and was not significantly different (P = .69). Between the 2 visits, 83.8% (n = 31) were classified identically with CES-D scores of 23 or higher, with moderate agreement between the 2 measures (kappa = 0.56).

DISCUSSION

Depression symptoms were relatively constant across the latter 2 trimesters of pregnancy. The second trimester may be an appropriate time to screen women for antenatal depression, as it is less likely to be affected by early-pregnancy somatic events yet is early enough that intervention may impart positive health benefits for mother and child.

Magnitude and risk factors for postpartum symptoms: a literature review

BACKGROUND

The prevalence of postpartum depression worldwide varies from 0.5% to 60.8% in the first 12 months postpartum using self-reported questionnaire. This review aims to update the current magnitude of postpartum depression based on self-reported questionnaire and clinical interview and explore its associated factors in developed and developing countries.

METHODS

A literature search conducted between 2005 and 2014 identified 203 studies, of which 191 used self-reported questionnaire in 42 countries and 21 used structured clinical interview in 15 countries. Nine studies used a combination of self-reported questionnaire and clinical interview.

RESULT

The prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries and from 5.2% to 74.0% in developed countries using self-reported questionnaire. Structured clinical interview shows a much lower prevalence range from 0.1% in Finland to 26.3% in India. Antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, stressful life events, negative attitude towards pregnancy, and lack of social support are significant contributors to postpartum depression.

LIMITATION

All studies are included irrespective of the methodological quality, such as small sample size and their inclusion could affect the generalizability of the results.

CONCLUSION

The current prevalence of postpartum depression is much higher than that previously reported, and similar risk factors are documented. A culturally sensitive cut-off score with adequate psychometric properties of the screening instruments should be available. In future studies, examining the physical, biological, and cultural factors in qualitative studies and in those with adequate methodological qualities is recommended.

Changes in PTSD symptomatology and mental health during pregnancy and postpartum

Changes in mental health symptoms throughout pregnancy and postpartum may impact a woman's experience and adjustment during an important time. However, few studies have investigated these changes throughout the perinatal period, particularly changes in posttraumatic stress disorder (PTSD) symptoms. The purpose of this study was to examine longitudinal changes in PTSD, depression, and anxiety symptomatology during pregnancy and postpartum. Pregnant women of ethnically diverse backgrounds receiving services for prenatal care at an outpatient obstetric-gynecology clinic or private physicians' office were assessed by interview on symptoms of PTSD, depression, anxiety, and general stress up to four times, including their first, second, and third trimester, and postpartum visits. Overall, during pregnancy there was a declining trend of PTSD symptoms. For anxiety, there was no overall significant change over time; however, anxiety symptoms were individually variable in the rate of change. For both depression and general stress symptoms, there was a declining trend, which was also variable in the individual rate of change among women during their pregnancy. Visual and post hoc analyses also suggest a possible peak in PTSD symptoms in the weeks prior to delivery. While most mental health symptoms may generally decrease during pregnancy, given the individual variability among women in the rate of change in symptoms, screening and monitoring of symptom fluctuations throughout the course of pregnancy may be needed. Further studies are needed to examine potential spiking of symptoms in the perinatal period.

Is screening for depression in the perinatal period enough? The co-occurrence of depression, substance abuse, and intimate partner violence in culturally diverse pregnant women

BACKGROUND

The perinatal period provides unique opportunities to identify and intervene with the co-occurrence of perinatal depression, intimate partner violence (IPV), and substance use problems. Psychosocial screening recommended for women seen in maternal child health settings tends to target single rather than multiple risk factors; there is limited research examining the co-occurrence of these issues especially in racially and ethnically diverse women across the perinatal period. These analyses explore the relationships of sociodemographic, psychosocial, and behavioral characteristics in a large, diverse sample of women.

METHOD

Women receiving perinatal services at routinely scheduled visits, including the 6-week postpartum visit, were recruited from 10 community obstetric/gynecologic clinics. Data were collected on perinatal depression, IPV, maternal substance use, and sociodemographic characteristics by bilingual, bicultural research assistants.

RESULTS

A total of 1868 women were screened, 1526 (82%) Latina, 1099 (58.8%) interviewed in Spanish; 20.4% (n=382) screened positive for depressive symptoms based on an Edinburgh Postnatal Depression Scale score of 10 or above, 20.9% reported harmful drinking, 4.3% reported drug use, 23% reported substance use problems, and 3.5% reported current or recent IPV. Women who were Black, Asian, Pacific Islander, or other race/ethnicity had greater odds for depressive symptoms relative to women who were Hispanic or Latino (odds ratio [OR]=1.81, p=0.005). Women reporting substance use problems (OR=2.37, p<0.0001) and IPV (OR=3.98, p<0.0001) had higher odds for depressive symptoms.

CONCLUSION

In a predominately Latina sample, 1 in 5 mothers (20.4%) screened positive for depressive symptoms and over one third (36.7%) reported one or more psychosocial issues during the perinatal period. Screening for multiple risk factors rather than just one can help clinicians tailor interventions for the successful management of psychosocial issues.

Coping strategies as psychological risk factor for antenatal anxiety, worries, and depression among Greek women

A range of psychosocial, medical, and demographic variables may influence pregnant women's psychological status. However the association between coping strategies, anxiety, worries, and depression during pregnancy is a relatively neglected area of research. Therefore, the aim of this study was to examine the relationship between coping strategies, antenatal anxiety, pregnancy worries, and depressive symptomatology after controlling for the effects of background variables. The study sample consisted of 163 pregnant women, with gestational age ranging from 11 to 26 weeks, attending antenatal screening at a Greek public hospital. Coping strategies were measured with Brief COPE, pregnancy worries were measured with Cambridge Worry Scale (CWS), anxiety was assessed using State-Trait Anxiety Inventory (STAI-X version), and depression was measured with Center for Epidemiologic Studies-Depression scale (CES-D). Pearson's correlation coefficients were calculated among all study variables, followed by hierarchical multiple linear regression. In the univariate analysis, low annual income, unemployment, conception after an IVF treatment, and a previous history of miscarriage were associated with anxiety, depression, and worries. Additionally, almost all coping strategies (denial, behavioral disengagement, self-blame, self-distraction, substance use, acceptance, positive reframing, active coping, and seeking emotional support) were significantly associated with antenatal anxiety, worries, and depression. Linear regression analysis showed that only previous history of miscarriage, conception after IVF, as well as denial, behavioral disengagement and acceptance coping strategies were significantly related to anxiety, worries and depressive symptomatology. The risk factors found in this study could help clinicians target anxiety and depression screening to high-risk populations of pregnant women. Provision of adequate training for obstetricians and midwives in the detection and management of anxiety and depression among pregnant women should help to decrease the psychological burden during pregnancy.

A nurse-led initiative to improve obstetricians' screening for postpartum depression

Although up to 20 percent of women experience postpartum depression, screening is not standard practice. In a metropolitan area where only 1 of 30 obstetricians and two primary care clinics reported routine screening for postpartum depression, a nurse-led initiative to implement routine screening using the Edinburgh Postnatal Depression Scale was carried out. Twenty-two obstetricians (76 percent) agreed to consistently implement screening for 3 months. Of the 21 participating obstetricians, 71.4 percent indicated that postpartum depression screening would become their standard care. This article describes implementation strategies and lessons learned.

Factors associated with clinically significant insomnia among pregnant low-income Latinas

BACKGROUND

Poor sleep, common during pregnancy, is associated with negative health risks. The study aimed to identify predictors of clinically significant insomnia among pregnant Latinas.

METHODS

A total of 1289 pregnant Latinas recruited from obstetric clinics completed the Insomnia Severity Index (ISI) and questions about demographics and sleep.

RESULTS

Clinically significant insomnia (ISI≥10) was present among 17% of participants. Significant correlates of clinically significant insomnia were higher scores on the Edinburgh Postnatal Depression Scale (EPDS) after removing the sleep item (47% of women with EPDS≥9 and 9% with EPDS<9), completing measures in English (rather than Spanish: 26% versus 13%), and income but not pregnancy week, age, highest education level, or marital status. The highest percentage of clinically significant insomnia (59%) was experienced by women with EPDS≥9 who completed measures in English. The lowest percentage of clinically significant insomnia (6.2%) was experienced by women with EPDS<9 who completed measures in Spanish.

CONCLUSIONS

In this sample of low-income, mostly Spanish-speaking pregnant Latinas, rates of clinically significant insomnia appear to be higher than rates among nonpregnant Latinas. Rates of clinically significant insomnia are particularly high among Latinas with elevated depressive symptom severity, a known risk for insomnia. Acculturation, as indicated by completing measures in English, may be another risk specific to Latinas, possibly owing to loss of some ethnicity-specific protective factors (e.g., social support, strong family ties, and group identity). It will be important to directly test this explanation in future research.

Trajectories of parenting behavior and maternal depression

This study investigated trajectories of maternal parenting behavior across the infants' first 18 months of life in relation to maternal depression. Furthermore, predictors of the quality of the mother-infant relationship at 18 months were examined. Participants consisted of three types of mother-infant dyads: mothers with comorbid depression and anxiety (n=19), mothers with depression (n=7) and nondepressed mothers (n=24). Maternal behaviors and the quality of relationship were rated on a global scale (NICHD) from video-taped mother-infant interactions. Maternal behaviors rated at six, 12 and 18 months were collapsed into a composite variable maternal style. The quality of the relationship captured as dyadic mutuality was rated at 18 months. Comorbid and depressed mothers showed lower quality in maternal style compared with the nondepressed mothers at six months. Over the follow-up the comorbid mothers were lower in maternal style compared to the nondepressed mothers, but the comorbid mothers increased significantly in maternal style despite elevated depression symptoms. Mean maternal style and infant cognitive skills predicted the quality in relationship at 18 months suggesting that the mother-toddler relationship depends on contributions from the mother and the child. Higher growth in maternal style despite of depression symptoms among comorbid mothers was interpreted against the background that the majority of the comorbid mother-infant dyads received several treatments.

Concurrent levels of maternal salivary cortisol are unrelated to self-reported psychological measures in low-risk pregnant women

Associations between salivary cortisol and maternal psychological distress and well-being were examined prospectively on 112 women with normally progressing, singleton pregnancies between 24 and 38 weeks gestation. At each of 5 visits, conducted in 3-week intervals, women provided a saliva sample and completed questionnaires measuring trait anxiety, depressive symptoms, pregnancy-specific hassles and uplifts, and psychological well-being. Maternal salivary cortisol was unrelated to psychological measures with the exception of minor associations detected with measures of anxiety and depressive symptoms between 30 and 32 weeks only. Findings indicate that self-reported maternal psychological distress and well-being are not associated with significant variation in maternal salivary cortisol levels during the second half of gestation. This suggests that studies that measure psychological factors in pregnancy but do not measure maternal cortisol should exercise caution in assuming activation of the maternal hypothalamic-pituitary-adrenal axis is the mechanism through which maternal psychological factors are transduced to the fetus.

A model for maternal depression

With the awareness of maternal depression as a prevalent public health issue and its important link to child physical and mental health, attention has turned to how healthcare providers can respond effectively. Intimate partner violence (IPV) and the use of alcohol, tobacco, and other drugs are strongly related to depression, particularly for low-income women. The American College of Obstetricians and Gynecologists (ACOG) recommends psychosocial screening of pregnant women at least once per trimester, yet screening is uncommonly done. Research suggests that a collaborative care approach improves identification, outcomes, and cost-effectiveness of care. This article presents The Perinatal Mental Health Model, a community-based model that developed screening and referral partnerships for use in community obstetric settings in order to specifically address the psychosocial needs of culturally diverse, low-income mothers.

Risk factors for postpartum depression among abused and nonabused women

OBJECTIVE

The objective of the study was to compare risk factors for postpartum depression among women exposed vs not exposed to intimate partner violence and to assess the timing of abuse in relation to postpartum depression.

STUDY DESIGN

This was a retrospective cohort study utilizing data from the Canadian Maternity Experiences Survey, a telephone survey at 5-10 months postpartum. Survey questions were adapted from the Canadian Violence Against Women Survey and the Edinburgh Post-Natal Depression Scale.

RESULTS

Among abused women, younger (15-19 years), and older (35 years old and older), age was associated with postpartum depression, adjusted odds ratio (aOR, 2.29; 95% confidence interval [CI], 1.17-4.51) and (aOR, 2.33; 95% CI, 1.02-5.34) as was unemployment (aOR, 1.41; 95% CI, 1.06-1.84), foreign birth (aOR, 2.04; 95% CI, 1.35-3.09], and low income (aOR, 1.68; 95% CI, 1.25-2.25) among nonabused women. Postpartum depression was significantly associated with abuse occurring only prior to pregnancy (aOR, 3.28; 95% CI, 1.86-5.81), starting postpartum (aOR, 4.76; 95% CI, 1.41-16.02), and resuming postpartum (aOR, 3.81; 95% CI, 1.22-11.88).

CONCLUSION

Among pregnant women, subgroups defined by abuse exposure differ in their risk profile for postpartum depression.

Maternal depression and sex differences shape the infants' trajectories of cognitive development

The effect of maternal depression on the trajectories of cognitive development was studied in 26 infants with depressed mothers as compared to a group of 24 infants with non-depressed mothers. The infants were tested on Mullen Scales of Early Learning when they were 6, 12 and 18 months old. Mothers reported their depressive symptoms over the follow ups. The study also investigated if there were sex differences in the cognitive trajectories. Multilevel modeling analyses revealed that infants of depressed mothers had a stable lower cognitive score over the period 6-18 months of age as compared to the infants of non-depressed mothers, and that the girls tended to increase their cognitive scores as compared to the boys over the same time period. The results are discussed in light of the stability of depression symptoms over the follow up and sex differences in cognitive development.

Violence and other stressful life events as triggers of depression and anxiety: what psychosocial resources protect African American mothers?

Understanding the risk and protective factors related to maternal mental health problems is important for improving the well-being of mothers and children, particularly in African American populations which may be at greater risk for maternal depression and resulting child behavior problems. This study explored whether three psychosocial resources--emotional resilience, social support, and ethnic identity--serve as protective factors in the face of specific stressful events that may trigger African American mothers' depression and anxiety symptoms. Standard self-report measures of depression, anxiety, negative life events, community violence, abuse, emotional resilience, social support, and ethnic identity were administered to African American mothers (N=209) of 2-18 month-old children. Linear regression models revealed main effects of negative life events and abuse on increased depression and anxiety symptoms, while emotional resilience and social support predicted decreased symptoms. There was also a significant interaction revealing a protective-reactive effect of ethnic identity on the associations of witnessed community violence with depression and anxiety symptoms. It is important for primary care providers to screen African American mothers for negative life events and abuse to identify those at increased risk for maternal depression and anxiety symptoms. Treatment programs should target emotional resilience, enhanced social support, and stronger ethnic group affiliation, which may be most effective at preventing mental health problems among mothers exposed to relative lower levels of community violence.

Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries

INTRODUCTION OR BACKGROUND

It is well established that postnatal depression (PND) is prevalent in high-income countries and is associated with negative personal, family and child developmental outcomes.

SOURCES OF DATA

Here, studies on the prevalence of maternal PND in low- and middle-income countries are reviewed and a geographical prevalence map is presented. The impact of PND upon child outcomes is also reviewed.

AREAS OF AGREEMENT

The available evidence suggests that rates of PND are substantial, and in many regions, are higher than those reported for high-income countries. An association between PND and adverse child developmental outcomes was identified in many of the countries examined.

AREAS OF CONTROVERSY

Significant heterogeneity in prevalence rates and impact on child outcomes across studies means that the true extent of the disease burden is still unclear.

AREAS TIMELY FOR DEVELOPING RESEARCH

Nonetheless, there is a compelling case for the implementation of interventions to reduce the impact of PND on the quality of the mother-infant relationship and improve child outcomes.

Associations of maternal psychological factors with umbilical and uterine blood flow

OBJECTIVE

Alteration to blood flow in the maternal-foetal compartment has been proposed as a mechanism underlying maternal psychological effects on pregnancy outcomes. This study characterised the progression of umbilical and uterine blood flow resistance in healthy pregnancies and evaluated concurrent and longitudinal associations with maternal anxiety and other psychological factors.

METHODS

The study assessed participants (n=107) at five visits spanning 24-38 weeks gestation. The resistance index (RI) in the uterine and umbilical arteries was measured with Doppler ultrasound. Maternal psychological function was assessed using validated, self-report instruments.

RESULTS

Hierarchical linear modelling revealed that uterine and umbilical RI decreased during the second half of gestation, and that uterine RI was lower in nulliparous women. Few concurrent associations emerged between psychological factors and RI. Longitudinal analyses determined that psychological well-being was associated with decreased left uterine artery RI, and psychological distress was associated with lower right artery RI.

CONCLUSIONS

Although uterine artery resistance was modestly associated with the maternal psychological milieu during gestation, our findings do not indicate an association between increased maternal distress and decreased RI. Thus, this study fails to affirm a key component of the hypothesised relation of maternal stress to foetal outcomes via vasoconstriction.

The Structure of Witnessed Community Violence amongst Urban African American Mothers: Latent Class Analysis of a Community Sample

The prevalence of witnessed community violence (WCV) amongst urban populations in the USA is striking. WCV can be harmful to one's psychological health, and for mothers, the consequences may be more far-reaching as their mental health affects parenting and child development. This study used telephone interviews (n = 209) to explore the patterns and covariates of WCV amongst a sample of urban, African American mothers of infants. Mothers reported whether they had witnessed 11 different forms of violence in their current neighborhoods. A latent class analysis revealed two distinct groups of mothers, those with higher versus lower-exposure to WCV. Mothers in the higher-exposure group were more likely to be low-income, to have a high school education or less, and to have higher anxiety scores than those in the lower-exposure group. Depression was not associated with higher exposure to WCV. Distinguishing between higher- and lower-exposure samples can inform the development of targeted prevention and intervention strategies for metropolitan areas.

Maternal distress explains the relationship of young African American mothers' violence exposure with their preschoolers' behavior

Adolescent mothers and their children are particularly susceptible to witnessing or directly experiencing violence. Such violence exposure predicts maternal distress, parenting, and child behavior problems. The current study examined how mothers' depressive symptoms, aggression, harsh disciplinary practices, and home environment independently explain the association between mothers' violence exposure and children's externalizing and internalizing behavior, controlling for their children's violence exposure. Data were collected from 230 African American mothers living in Washington, DC who gave birth as adolescents and whose children were 3 to 5 years old. Path analysis revealed that the effect of mothers' experienced violence on children's externalizing and internalizing behavior was mediated by mothers' depressive symptoms and aggression. However, neither harsh discipline nor stimulation in the home environment acted as significant mediators, and there were no direct or indirect effects of mothers' witnessed violence on child behavior. This study builds on previous work by identifying an association between maternal violence exposure and children's behavior, independent of children's own violence exposure that is explained by mothers' increased distress but not their parenting. These findings suggest that a potential means of preventing behavior problems in minority children born to adolescent mothers is to identify mothers who have been directly exposed to violence and treat their depressive symptoms and aggressive behaviors.

Self-reported depressive symptoms and parental stress in mothers and fathers who bring their infants to an infant mental health clinic

BACKGROUND

The parental functioning and its influence upon infant mental health development have been extensively studied but there are few clinical studies investigating less severe psychiatric problems among mothers and fathers in the same family.

AIM

This study focuses on the emotional well-being of mothers and fathers who bring their infants to an Infant Mental Health Clinic.

METHODS

The studied sample is comprised of 63 families with 0-47-month-old infants where the mothers completed the Center for Epidemiological Study-Depression Scale (CES-D), including 43 families in which the CES-D was completed by both parents. In 44 families, the mothers also filled in the Swedish Parental Stress Questionnaire (SPSQ), including 32 where the SPSQ was completed by both parents. The children were independently classified with the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3).

RESULTS

Altogether, 54% of the mothers and 11% of the fathers reported depressive symptoms above the CES-D clinical cut-off. Self-rated depressive symptoms and parental stress were strongly related. The mothers' self-rated depressive symptoms were associated with the severity of their infant's problems, but the association was not specific to the DC 0-3 Axis I classification. The mothers' stress level was marginally related to DC 0-3 Axis II relationship classification.

CONCLUSION

The results indicate that the inclusion of systematic parental self-ratings in infant mental health assessments could add clinical information facilitating the planning of family oriented interventions.